Abstract
Background:
The aim of our study was an objective integrated assessment of the functional outcomes of reduction mammaplasty.
Methods:
The study involved 17 women undergoing reduction mammaplasty from March 2009 to June 2011. Each patient was assessed before surgery and 2 months postoperatively with the original association of 4 subjective and objective assessment methods: a physiatric clinical examination, the Roland Morris Disability Questionnaire, the Berg Balance Scale, and a static force platform analysis.
Results:
All of the tests proved multiple statistically significant associated outcomes demonstrating a significant improvement in the functional status following reduction mammaplasty. Surgical correction of breast hypertrophy could achieve both spinal pain relief and recovery of performance status in everyday life tasks, owing to a muscular postural functional rearrangement with a consistent antigravity muscle activity sparing. Pain reduction in turn could reduce the antalgic stiffness and improved the spinal range of motion. In our sample, the improvement of the spinal range of motion in flexion matched a similar improvement in extension. Recovery of a more favorable postural pattern with reduction of the anterior imbalance was demonstrated by the static force stabilometry. Therefore, postoperatively, all of our patients narrowed the gap between the actual body barycenter and the ideal one. The static force platform assessment also consistently confirmed the effectiveness of an accurate clinical examination of functional impairment from breast hypertrophy.
Conclusions:
The static force platform assessment might help the clinician to support the diagnosis of functional impairment from a breast hypertrophy with objectively based data.
A large number of studies focused on the benefits of a reduction mammaplasty on breast hypertrophy-related functional impairments are reported in the literature.1–12 Nevertheless, the vast majority of these reports are actually supported by subjectively based data from quality of life questionnaires. The only exception in such a homogeneous context is a study where the pulmonary function was objectively evaluated before and after surgical correction of breast hypertrophy with a reduction mammaplasty.13
Recently, a new method was introduced to objectively analyze postural variations after a breast reduction by means of static stabilometry.14
The aim of our study is an integrated assessment of the functional outcomes of reduction mammaplasty. Evaluation was carried out with the integration of 4 different subjective and objective methods: a full clinical physiatric examination, the Roland Morris Disability Questionnaire (RMDQ) for low back pain, the Berg Balance Scale (BBS), and a new static force platform.
MATERIALS AND METHODS
The study was carried out in cooperation with the Plastic Surgery Unit, University of Pavia, Salvatore Maugeri Research and Care Institute and the Physical Medicine and Rehabilitation Unit, University of Pavia, San Matteo Research and Care Institute, Pavia, Italy.
Seventeen women undergoing reduction mammaplasty for breast hypertrophy were enrolled in the study over a period of 2 years, from March 2009 to June 2011. The mean age was 43.7 years (minimum 15, maximum 59, and median 46). The average body mass index (BMI) was 29 (minimum 23, maximum 36, and median 28). Each patient was assessed before surgery and 2 months postoperatively. A formal informed written consent was obtained from all of the patients.
Physiatric Clinical Examination
All of the clinical signs and symptoms were scored as in a binary system (0–1).
Kyphosis: normal = 0, pathological = 1
Lordosis: normal = 0, pathological = 1
Range of motion (ROM) of the lumbar spine: flexion > 40° = 0, flexion < 40° = 1; extension > 15° = 0, extension < 15° = 1
Sensitivity alterations in lower and upper limbs: no alterations = 0, sensitivity alterations = 1
Reported cervical and lumbar pain: no pain = 0, pain = 1
Variations of the postoperative status vs the preoperative one were expressed using a semiquantitative scale:
−1 = improved (less disability)
0 = stable
+1 = worsened (more disability).
Roland Morris Disability Questionnaire
The RMDQ is one of the most popular tools for clinical evaluation of pain-related lumbar spine disability. It assesses the low back pain through 24 items providing a numerical score ranging from 0 (no disability) to 24 (severe disability). A previously validated, translated, and culturally adapted version of the original RMDQ was used for our sample of Italian patients.15
Berg Balance Scale
The BBS is one of the most reliable tools for clinical assessment of balance ability. The scale is performance oriented and consists of 14 movements common in everyday life with quantitative scores ranging from 0 (severe disability) to 56 (no disability).16
ARGO Static Force Platform
The ARGO (R.G.M. Medical Devices S.p.A., Genoa, Italy) static force platform is designed to measure the instantaneous position of the center of pressure which, by balancing the couple produced by the force of weight, ensures maintenance of the upright position.
It has a large platform surface area (600 × 600 mm) for execution of circular kick and a high sampling frequency (100 Hz) that allows analysis of sway density parameters and provides data for obtaining a reliable harmonic analysis even with short measurement times (Fig. 1).
Fig. 1.
The static force platform.
All test parameters are relative to the path followed by the center of pressure:
Sway area (extent of the area covered by the center of pressure, in mm2)
Ellipse area (elliptic section of the sway area including 95% of the centers of pressure, in mm2)
Anteroposterior (AP) maximum oscillation, in mm
Side maximum oscillation, in mm
Sway path (oscillation speed, in mm/s)
Mean distance between 2 consecutive centers of pressure, in mm
AP distance between the center of the ellipse area and the geometric barycenter of the body in mm. In the ideal orthostatic balance, the center of the ellipse and the geometric barycenter coincide.
The patients were assessed on the platform in quiet standing through 4 different modalities: close parallel feet-open eyes (PFOE), close parallel feet-closed eyes (PFCE), slightly spread feet-open eyes (SFOE), and slightly spread feet-closed eyes (SFCE). Each assessment lasted 40 seconds preceded by a 5-second waiting time that allowed the patient to become familiar with the position, thus reducing the adaptation artifacts17–24 (Fig. 2).
Fig. 2.
Patient in quiet standing during assessment on the static force platform.
Reduction Mammaplasty
All patients underwent a vertical reduction mammaplasty according to a personal technical variation.25 A standard “C cup” breast mound was reshaped whatever the breast size preoperatively. The average breast tissue removed was 1720 g per patient (minimum 574 g, maximum 3434 g, and median 1632 g).
Statistical Analysis
Quantitative variables regarding the static force platform have been normalized according to the following formula: 100 × (t2 − t1)/t1, where t1 represents the measurement at time 1 (preoperative time) and t2 represents the measurement at time 2 (postoperative time). Deviations from the normal distributions of quantitative variables have been tested by the Shapiro test for normality: P < 0.05 has been set as the significance threshold for identifying variables that did not follow the normal distribution. As none of the quantitative variables followed the normal distribution, nonparametric tests have been applied. Differences in terms of quantitative variables between 2 subgroups have been evaluated by the Wilcoxon test for paired samples (for comparing distributions at t1 vs t2). Differences in terms of quantitative variables for nonpaired samples have been tested by the Wilcoxon rank-sum test (when comparing quantitative distributions between binary levels) or by the Kruskal-Wallis test (when comparing quantitative distributions between 2 or more levels). Frequency distributions have been tested by the Fisher’s exact test. The binomial test has been used for evaluating whether the proportion of patients improving their health condition was significantly higher than what expected by chance. P-values < 0.05 have been considered statistically significant. All statistical procedures have been performed by the R statistical software (http://www.r-project.org/).
RESULTS
Physiatric Clinical Examination
The results of the physiatric clinical examination are depicted in Table 1. We compared the distribution of binary variables at postoperative time vs preoperative time.
Table 1.
Scores of Postoperative Physiatric Signs and Symptoms
The fraction of patients reporting a reduced lumbar pain score postoperatively rather than preoperatively (thus corresponding to a better condition) is significantly higher than the expected fraction of patients reporting a reduced lumbar pain score by chance (observed fraction = 0.59; expected fraction by chance = 0.33; P < 0.05).
Patients showing an improved spinal extension ROM in t2 vs t1 are more likely to reach a corresponding improved spinal flexion ROM (67% vs 10%, P < 0.05).
The other clinical signs and symptoms failed to show any statistically significant improvement.
Roland Morris Disability Questionnaire
The results of the RMDQ are depicted in Figure 3.
Fig. 3.
Graphic report of the distribution of values obtained with the RMDQ at t1 vs t2. At t2, the values are gathered in the area corresponding to the lesser perceived disability. The scarlet spots in the graphic are the median values. The single high isolated red spot at t2 is the only case that referred a worse postoperative outcome.
The most frequently selected items in the questionnaire are depicted in Table 2.
Table 2.
Results of the Most Selected Items in the RMDQ Questionnaire
The median values of the RMDQ are summarized in Table 3.
Table 3.
Median Values of the RMDQ
The median value of the RMDQ at t2 is significantly lower than the corresponding value at t1 (t1: median = 7; interquartile range = 5; t2: median = 2; interquartile range = 2; P < 0.01).
Berg Balance Scale
The results of BBS are depicted in Figure 4.
Fig. 4.
Graphic report of the distribution of values obtained with the BBS at t1 vs t2. At t2, the values are gathered in the area corresponding to better balance ability. The scarlet spots in the graphic are the median values.
The median values of BBS are summarized in Table 4.
Table 4.
Median Values of the BBS
The median value of BBS at t2 is significantly higher than the corresponding value at t1 (t1: median = 48; interquartile range = 14; t2: median = 55; interquartile range = 6; P < 0.01).
ARGO Static Force Platform
Among the myriad of data resulting from the static force platform, we analyzed 4 parameters as the most reliable for our purposes:
The AP distance (in mm) between the center of the ellipse area and the real geometric barycenter of the body, in SFOE and SFCE position.
The stay time (in s) in SFCE position.
The ellipse area (in mm2) in PFOE position.
The sway area (in mm2/s) in PFOE position.
Results show that the median value of the normalized measurements of AP (t2 vs t1) is significantly different from 0 (P < 0.05) as the real barycenter tends to reach the ideal one (Fig. 5). In other words, after breast reduction, all of the patients tend to assume a more balanced standing position as they reduce the anterior imbalance of the trunk.
Fig. 5.
Graphic report of the distribution of normalized values of AP distance from the ideal barycenter at t1 vs t2. The values show a slight general improvement of this parameter.
Furthermore, longer stay time and reduction of the ellipse and the sway area are significantly related to RMDQ scores and spinal ROM (Table 5). This suggests that patients who display an increased stay time in the instant centers of pressure and a reduction of the oscillation area show better performance in everyday life tasks and are more likely to improve their spinal ROM too.
Table 5.
Association of RMDQ with 2 Static Force Platform Parameters
Further Statistically Significant Cross-matched Correlations
We observed significant correlations (P < 0.05) between variations of single variables and variations of cervical pain and lumbar pain (t2 vs t1).
Associations with lumbar pain (Table 6):
Table 6.
Association of Lumbar Pain with BBS and 1 Static Force Platform Parameter
Lesser lumbar pain conditions in t2 vs t1 are associated with higher positive variations of BBS at t2 vs BBS at t1 with respect to those who show no improvement.
Similarly, lesser lumbar pain conditions in t2 vs t1 are associated with higher variations of AP distance of the real barycenter from the center of the ellipse in the SFCE position. And so, the patients who tend to reduce the anterior displacement of the barycenter are more likely to reduce the lumbar pain as well.
Associations with cervical pain (Table 7):
Table 7.
Association between Cervical Pain and Removed Breast Tissue
Patients who displayed a higher improvement in cervical pain at t2 vs t1 were those in whom lesser amounts of breast tissue were removed.
We also observed significant correlations between variations in the amount of removed breast tissue and BBS (t2 vs t1) (Table 8). This shows that those who have had a higher amount of breast tissue removed are more likely to show greater and positive variations of BBS.
Table 8.
Association between BBS and Removed Breast Tissue
We also observed significant correlations between variations of single variables and RMDQ (t2 vs t1) (Table 9).
Table 9.
Association of RMDQ with Body Mass Index and Age
Age: Older patients tend to have more negative variations of RMDQ at t2 vs t1 than the younger ones. Indeed, older patients seem to benefit from the operation more than the younger ones in everyday life activities.26
BMI: Patients with higher BMI are more likely to reach more negative variations of RMDQ at t2 vs t1 than those with lower BMI. Overweight patients seem to benefit from the operation more than the thinner ones in everyday life activities. BMI is also significantly associated with the quantity of breast tissue removed (r = 0.5, P = 0.05). In other words, the higher the BMI, the higher the quantity of breast tissue removed.
DISCUSSION
Breast hypertrophy causes a myriad of symptoms, the most common being pain, psychosocial discomfort, and skin lesions.
The increased weight of the breasts causes several spinal postural alterations, such as dorsal kyphosis and anterior shoulder dislodgement, that may eventually lead to morphological stable alterations in the growing individual or degenerative changes in the adult. Anterior shoulder dislodgement and dorsal kyphosis may also be exacerbated by the psychological attitude to disguise the large volume of the breasts. Dorsal kyphosis is somewhat compensated by an increase of the lumbar lordosis which in turn leads to a prominent abdomen.27,28 Such a complex postural alteration tends to directly involve the cervical spine too, with persistent contraction of the cervical spine stabilizing muscles (trapezius and cervical paravertebral muscles). The sequence of events so far described eventually leads to the so-called pain chain: a continuous spinal pain starting at the lumbar level and progressively extending to the cervical spine with shoulder irradiation.
The combined increased lumbar lordosis and dorsal kyphosis complex is demonstrated to reduce the overall ability to keep a stable balance and to perform dynamic tasks requiring a stable balance.
Such a clinical picture is actually better defined as a marked discomfort rather than a proper disability. Also in our sample the actual disability from breast hypertrophy was modest and was consistently displayed by the preoperative median scores of the physiatric clinical examination, the BBS, and the RMDQ. Such a light status of disability included altered balance control, reduced performance in everyday life tasks, lumbar pain, cervical pain, reduced flexion, and extension ROM in the spine.
In our experience, all of the tests consistently demonstrated across the whole sample range a significant improvement in the functional status following a reduction mammaplasty.
The physiatric clinical examination, the BBS, the RMDQ, and the static force platform balance assessment demonstrated multiple statistically significant associated outcomes.
The RMDQ showed a remarkable functional recovery with reduction to almost zero the residual levels of disability at the postoperative time.
Older patients and those with a higher body mass index, although affected by a higher degree of disability before surgery, postoperatively achieved the same performance status as the younger ones and those with a lesser body mass index, thus displaying a higher delta between the pre- and postoperative time. Such a result might be explained by supposing that as age and being overweight are impairing conditions in everyday life activities, breast hypertrophy might be even more disabling for those patients. Vice versa, in the younger and normal-weight patients, the potential impairment in everyday life tasks from a breast hypertrophy is more compensated by some sort of higher functional reserve. The higher delta in the postoperative recovery in the overweight patients might be related to the increased quantity of breast tissue removed.
The BBS demonstrated a body balance improvement, consistent with data from static force stabilometry. Indeed, the static force platform demonstrated a statistically significant reduction of the AP distance between the center of the ellipse area and the geometric barycenter of the body in all of the patients after breast reduction. Such an outcome demonstrates recovery of a more favorable postural pattern with reduction of the anterior imbalance. Therefore, postoperatively, all of our patients narrowed the gap between the actual body barycenter and the ideal one.
The physiatric clinical examination demonstrated a dramatic decrease of lumbar pain in 10 out of 17 patients. Such an outcome is related to the antigravity muscle action sparing that follows a breast reduction.
Pain reduction in turn reduces the antalgic stiffness and improves the spinal ROM. In our sample, the improvement of the spinal ROM in flexion matched a similar improvement in extension.
The low back pain relief matched an improved balance status as proved by the statistically significant association of the physiatric clinical examinations with both the BBS and the static force platform. Such an improvement in the balance status concerned both the ability in everyday life tasks and a marked reduction of the anterior imbalance of the body. In the latter postoperative outcome, the actual barycenter approached the ideal one.
The pain reduction and the performance improvement in everyday life tasks demonstrated by the RMDQ matched the increased balance in terms of increased stay time in the instant centers of pressure and overall reduction of the oscillation area.
An apparently paradoxical outcome was observed in our sample where the larger the removed breast volume the lesser the cervical pain relief. Such a figure might be explained with the irreversible consolidation of the chronic cervical pain in the largest and long-standing breast hypertrophies. Furthermore, surgical correction of breast hypertrophy could not correct any anatomically stabilized spinal deformity.
On the contrary, the greater the volume of breast removed, the better the performance of everyday life tasks as demonstrated by the BBS.
The statistically significant associations of the outcomes from the traditional tests with those from the static force platform mutually cross-validates all of the assessment methods. The static force platform assessment might therefore help the clinician to support the diagnosis of functional impairment from a breast hypertrophy with objectively based data.
Considering breast reduction alternatively as a functional or a cosmetic operation has long been debated in the literature,29–37 and still it is an open issue for insurance companies and National Health Systems.
In a former publication,38 we proposed an objective anthropometric discriminating criterion to differentiate a functional from a cosmetic breast reduction. The association of an anthropometric criterion with an objective static force platform assessment might be a further proposal to definitely justify the functional indication for breast reduction.
CONCLUSIONS
Surgical correction of breast hypertrophy can achieve both spinal pain relief and recovery of performance status in everyday life tasks, owing to a functional rearrangement of postural muscles with a consistent work sparing of antigravity muscles. Breast hypertrophy should be surgically corrected in the earlier stages to maximize such a spinal pain relief. Nevertheless, reduction mammaplasty is not likely to reverse any chronically stabilized spinal deformities and to get maximum benefit a physiotherapy protocol should follow surgery.39
The static force platform assessment consistently confirmed the effectiveness of an accurate clinical examination of functional impairment from breast hypertrophy.
ACKNOWLEDGMENTS
We thank Alan Serge McGhee, MSc, Glasgow City Council Education Department, for his contribution to the submission of this dissertation. We also thank Floriana Cazzola and Gian Mario Pelizzoli for their much appreciated technical support.
Footnotes
Disclosure: The authors have no financial interest to declare in relation to the content of this article. The Article Processing Charge was paid for by the authors.
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